Postprandial hyperglycemia: a new frontier in diabetes management?

Postprandial hyperglycemia is one of the earliest abnormalities of glucose homeostasis associated with type-2 diabetes and it is markedly exaggerated in diabetic patients with fasting hyperglycemia. An extensive body of data demonstrates a strong association between postprandial glucose levels and cardiovascular risk factors. Our article will focus on the concept of postprandial hyperglycemia, its physiopathology, its role on cardiovascular risk factors and the effects of new devices and a new faster insulin analog on postprandial hyperglycemia

Linea Guida Multisocietaria per il paziente adulto con diabete o con iperglicemia ricoverato in setting clinico non critico

Introduzione Gruppo di sviluppo della Linea Guida Caratteristiche di una Linea Guida dell’ISS pubblicata sul Sito Nazionale Linee Guida Elenco dei quesiti Quesito 1: premesse, sintesi delle evidenze, raccomandazione, commento Quesito 2: premesse, sintesi delle evidenze, raccomandazione, commento Quesito 3: premesse, sintesi delle evidenze, raccomandazione, commento Quesito 4: premesse, sintesi delle evidenze, raccomandazione, commento Quesito 5: premesse, sintesi delle evidenze, raccomandazione, commento Quesito 6: premesse, sintesi delle evidenze, raccomandazione, commento Quesito 7: premesse, sintesi delle evidenze, raccomandazione, commento Quesito 8: premesse, sintesi delle evidenze, raccomandazione, commento Quesito 9: premesse, sintesi delle evidenze, raccomandazione, commento Quesito 10: premesse, sintesi delle evidenze, raccomandazione, commento Quesito 11: premesse, sintesi delle evidenze, raccomandazione, commento Quesito 12: premesse, sintesi delle evidenze, raccomandazione, commento Discussione Conclusion

Clinical outcomes of a digitally supported approach for self-management of type 2 diabetes mellitus

BackgroundSelf-management of Type 2 diabetes mellitus (T2D) is challenging. Regular self-monitoring of blood glucose and healthy lifestyles are required to improve glycometabolic control, thus delaying diabetes complications, and reducing hospitalizations. Digital technologies can empower patients in their disease management promoting self-management and motivation to change behaviors. We report the results of an exploratory trial aimed at evaluating the metabolic outcomes of using digital solutions for T2D self-management developed in the ProEmpower project, a European Commission funded Pre-Commercial Procurement.MethodsTwo digital solutions, DM4All and DiaWatch, which were codesigned with providers, patients, and caregivers, enabled the collection of clinical parameters by the patient using a smartphone integrated with the medical devices (glucometer, sphygmomanometer, scale, smart watch for heart rate monitoring and step counter). Data were automatically sent to the shared care plan allowing professionals to monitor adherence to treatment, set goals, and communicate more effectively with patients. At baseline and after an average follow-up of 8 months, glycosylated hemoglobin (HbA1c), body weight, blood pressure, and blood lipids were measured in 100 T2D patients using the ProEmpower solutions across different diabetes centers in Campania Region, age 45–79  years, both genders, and compared with a Control cohort of T2D patients (n = 100) with similar clinical characteristics and followed for a comparable period of observation in the same centers.ResultsAt baseline, the ProEmpower participants and the Control subjects were on average overweight, with a similar BMI in the two cohorts, and mean HbA1c was at acceptable levels (around 7.0%). After the 8 month exploratory trial, body weight, HbA1c, systolic and diastolic blood pressure, and plasma and LDL-cholesterol significantly decreased in the ProEmpower participants compared to baseline (p < 0.05 for all). The changes in systolic and diastolic blood pressure, and plasma and LDL-cholesterol were significantly different from those observed in the Control cohort (p < 0.05 for all).ConclusionThis pilot study showed positive effects on metabolic outcomes relevant to cardiovascular risk in T2D of adopting digital telemedicine self-monitoring solutions based on automation of measurements and coaching on healthy lifestyles promotion

Role of continuous glucose monitoring in diabetic patients at high cardiovascular risk. an expert-based multidisciplinary delphi consensus

Background: Continuous glucose monitoring (CGM) shows in more detail the glycaemic pattern of diabetic subjects and provides several new parameters (“glucometrics”) to assess patients’ glycaemia and consensually guide treatment. A better control of glucose levels might result in improvement of clinical outcome and reduce disease complications. This study aimed to gather an expert consensus on the clinical and prognostic use of CGM in diabetic patients at high cardiovascular risk or with heart disease. Methods: A list of 22 statements concerning type of patients who can benefit from CGM, prognostic impact of CGM in diabetic patients with heart disease, CGM use during acute cardiovascular events and educational issues of CGM were developed. Using a two-round Delphi methodology, the survey was distributed online to 42 Italian experts (21 diabetologists and 21 cardiologists) who rated their level of agreement with each statement on a 5-point Likert scale. Consensus was predefined as more than 66% of the panel agreeing/disagreeing with any given statement. Results: Forty experts (95%) answered the survey. Every statement achieved a positive consensus. In particular, the panel expressed the feeling that CGM can be prognostically relevant for every diabetic patient (70%) and that is clinically useful also in the management of those with type 2 diabetes not treated with insulin (87.5%). The assessment of time in range (TIR), glycaemic variability (GV) and hypoglycaemic/hyperglycaemic episodes were considered relevant in the management of diabetic patients with heart disease (92.5% for TIR, 95% for GV, 97.5% for time spent in hypoglycaemia) and can improve the prognosis of those with ischaemic heart disease (100% for hypoglycaemia, 90% for hyperglycaemia) or with heart failure (87.5% for hypoglycaemia, 85% for TIR, 87.5% for GV). The experts retained that CGM can be used and can impact the short- and long-term prognosis during an acute cardiovascular event. Lastly, CGM has a recognized educational role for diabetic subjects. Conclusions: According to this Delphi consensus, the clinical and prognostic use of CGM in diabetic patients at high cardiovascular risk is promising and deserves dedicated studies to confirm the experts’ feeling

Insulin therapy in the hospital setting: a time for a change?

The number of people with diabetes mellitus worldwide is expected to be more than double from 171 million in 2000 to 366 million in 2030. Approximately 25% of all hospital inpatient days are affected by diabetes. In Italy there are more than 12,000 hospitalizations excesses for 100,000 people per year, with a huge economic impact. Ever since its discovery in the 1920s, insulin has been the milestone of type 1 diabetes treatment and its use is increasingly necessary for the successful management of type 2 diabetes. Often patients believe that injecting insulin can be painful, inconvenient and embarrassing; generally they are afraid of gaining weight and of hypoglycemia. On the other side, physician’s concerns regarding insulin administration include potential dosing errors and patient non-compliance. Ever since its discovery in the mid-1920s, insulin was administered subcutaneously using a vial and syringe. In 1985 the first pen device was launched. Currently disposable insulin pens are the most used and preferred by patients in the daily use, but are not routinely used for diabetic inpatients. In this paper we will focus on the pros and cons of insulin administration with pens in the hospital setting

Results of an observational retrospective multicenter study: “Campania INternal medicine - the Clinical INternist for heart failure”

Introduction. The Campania population is characterized by a high incidence and prevalence of heart failure (HF). The aim of this study is to describe the clinical epidemiology, comorbidities, and treatments in HF patients admitted to Internal Medicine Wards (IMW) in Campania. Materials and Methods. It is a retrospective, regional, multicentric, observational study including patients admitted to 15 IMW in Campania, with an HF diagnosis, over a period of three consecutive months. Results. We identified 427 patients, stratified by ejection fraction (EF) category (127 EF≤40%; 216 EF 41-49%; 84 EF≥50%). In comparison with HFpEF subjects, patients with HFrEF were younger (74 years vs. 9 years), more commonly male (67% vs. 32%), and more likely to have an ischaemic aetiology (45% vs. 25%). The most used drugs at the time of hospitalization and after were Diuretics (80.3/93.5%), BBs (69.6/92.6%), and Statins (52.1/63.7%), with statistically significant pre-/post- differences (P≤0.05). Conclusions. EF is more likely to be non-preserved in younger males and in patients with CAD etiology. Hospitalization influences in a statistically significant way the change or adjustment of therapy for almost all drugs

The discharge of patients with diabetes from Internal Medicine Units: a clinical audit

The aim of the present study was to address it by conducting a clinical audit, one that focused on the quality evaluation of the assistance given to patients with diabetes at the moment of their discharge from hospital. The clinical audit was structured in 5 phases: i) preparation; ii) definition of criteria, indicators and standards; iii) retrospective data collection; iv) data analysis, identification of main deviations from standards; v) implementation of corrective measures. Twenty Departments of Internal Medicine from 10 Italian regions retrospectively reviewed medical reports obtaining a data collection from 1332 discharged patients with diabetes. Patients receiving instructions for home glycemic control/discharged patients, showed a mean performance =41.6% (range: 5.0-89.9); patients receiving instructions for hypoglycemic treatment/discharged patients, =32.4% (range: 0.0-92.1); patients receiving instructions for subcutaneous insulin administration/discharged patients, =60.4% (range: 56.5-100.0); patients receiving nutritional scheme or advice/discharged patients, =24.8 (range: 25.4-76.6); patients addressed to ambulatory control/discharged patients, =60.7% (range: 65.6-100.0); and finally patients with HbA1c reported in discharge report/discharged patients, =40.6% (range: 1.75-98.0). Results confirmed that all the levels are well below 70%, the acceptable level of quality. The clinical audit provided data that allows for better identification of deficient clinical behaviors and the addressing of them with specific ameliorative actions; a continuing process of check, re-check and feedback in order to further enhance the quality of assistance given to patients with diabetes discharged from hospital

Clinical governance and internal medicine: a marriage of convenience?

Amplification in health expectations, increase in new technologies, decrease in economic resources and the breakdown of traditional control systems have led to the development of clinical governance (CG). The aim of the present pilot study was to investigate the application of CG tools in significant sample of Italian internal medicine wards (IMW). A 37-item questionnaire was developed and administered to 39 physicians, within 33 IMWs throughout Italy. Thanks to the data analysis, the perceived usefulness, the utilization rate of CG tools, the correlations between CG use, wards characteristics, and/or localization were studied. We identified at what organizational level the CG tools were applied and used. fifty-two percent of the studied tools were being used in the investigated hospitals. The average utility and utilization rate was different depending on the region of provenance. This research showed that CG is a methodology often used by Italian hospitals physicians, especially for inpatient care. The encouraging results of this pilot study could suggest opportunities to extend the survey at national level, to generalize the results